Source: http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act
Senate
The Senate began work on its own proposals while the House was still working on the Affordable Health Care for America Act. Instead, the Senate took up H.R. 3590, a bill regarding housing tax breaks for service members.[88] As the United States Constitution requires all revenue-related bills to originate in the House,[89] the Senate took up this bill since it was first passed by the House as a revenue-related modification to the Internal Revenue Code. The bill was then used as the Senate's vehicle for their healthcare reform proposal, completely revising the content of the bill.[90] The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate Health and Finance committees. With the Republican minority in the Senate vowing to filibuster any bill that they did not support, requiring a cloture vote to end debate, 60 votes would be necessary to get passage in the Senate.[91] At the start of the 111th Congress, Democrats had only 58 votes; the Senate seat in Minnesota which would ultimately be declared in favor of Al Franken was still undergoing a recount, and Arlen Specter was still a Republican.
To reach 60 votes, negotiations were undertaken to satisfy the demands of moderate Democrats, and to try to bring aboard several Republican senators; particular attention was given to Bob Bennett, Mike Enzi, Chuck Grassley, and Olympia Snowe. Negotiations continued even after July 7 — when Franken was sworn into office, and by which time Specter had switched parties — due to disagreements over the substance of the bill, which was still being drafted in committee, and because moderate Democrats hoped to win bipartisan support. However, on August 25, before the bill could come up for a vote, Ted Kennedy—a long-time advocate for healthcare reform—died, depriving Democrats of their 60th vote. Before the seat was filled, attention was drawn to Senator Snowe because of her vote in favor of the draft bill in the Finance Committee on October 15, however she explicitly stated that this did not mean she would support the final bill.[75] Paul Kirk was appointed as Senator Kennedy's temporary replacement on September 24.
Following the Finance Committee vote, negotiations turned to the demands of moderate Democrats to finalize their support, whose votes would be necessary to break the anticipated Republican filibuster. Majority leader Harry Reid focused on satisfying the centrist members of the Democratic caucus until the holdouts narrowed down to Joe Lieberman of Connecticut, an independent who caucused with Democrats, and Ben Nelson, a conservative Democrat, representing Nebraska. Lieberman, despite intense negotiations in search of a compromise by Reid, refused to support a public option; a concession granted only after Lieberman agreed to commit to voting for the bill if the provision were not included,[75][92] although it had majority support in Congress.[93] There was debate among supporters of the bill about the importance of the public option,[94] although the vast majority of supporters concluded it was a minor part of the reform overall,[92] and that congressional Democrats' fight for it won various concessions, including conditional waivers allowing states to set up state-based public options such as Vermont's Green Mountain Care.[93][95]
With every other Democrat now in favor and every other Republican now overtly opposed, the White House and Reid moved on to addressing Senator Nelson's concerns in order to win filibuster-proof support for the bill;[96] they had by this point concluded "it was a waste of time dealing with [Snowe]"[97] because, after her vote for the draft bill in the Finance Committee, Snowe had come under intense pressure from the Republican Senate leadership who opposed the ACA.[98] After a final 13-hour negotiation, Nelson's support for the bill was won after two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges", which would require consumers to pay for the procedure out-of-pocket if the state so decided; and an amendment to offer a higher rate of Medicaid reimbursement for Nebraska.[70][99] The latter half of the compromise was derisively called the "Cornhusker Kickback"[100] and was later repealed by the subsequent reconciliation amendment bill.
On December 23, the Senate voted 60–39 to end debate on the bill: a cloture vote to end the filibuster by opponents. The bill then passed by a vote of 60–39 on December 24, 2009, with all Democrats and two independents voting for, and all Republicans voting against (except for Jim Bunning, who did not vote).[101] The bill was endorsed by the AMA and AARP.[102]
Several weeks after the vote, on January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the late Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain Republican filibusters.[70][103][104] The special election had become significant to the reform debate because of its effects on the legislative process. The first was a psychological one: the symbolic importance of losing the traditionally Democratic Massachusetts seat formerly held by Senator Ted Kennedy, a staunch supporter of reform, made many congressional Democrats concerned about the political cost of passing a bill.[105][106] The second effect was more practical: the loss of the Democratic supermajority complicated the legislative strategy of reform proponents.[106]
Senate
The Senate began work on its own proposals while the House was still working on the Affordable Health Care for America Act. Instead, the Senate took up H.R. 3590, a bill regarding housing tax breaks for service members.[88] As the United States Constitution requires all revenue-related bills to originate in the House,[89] the Senate took up this bill since it was first passed by the House as a revenue-related modification to the Internal Revenue Code. The bill was then used as the Senate's vehicle for their healthcare reform proposal, completely revising the content of the bill.[90] The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate Health and Finance committees. With the Republican minority in the Senate vowing to filibuster any bill that they did not support, requiring a cloture vote to end debate, 60 votes would be necessary to get passage in the Senate.[91] At the start of the 111th Congress, Democrats had only 58 votes; the Senate seat in Minnesota which would ultimately be declared in favor of Al Franken was still undergoing a recount, and Arlen Specter was still a Republican.
To reach 60 votes, negotiations were undertaken to satisfy the demands of moderate Democrats, and to try to bring aboard several Republican senators; particular attention was given to Bob Bennett, Mike Enzi, Chuck Grassley, and Olympia Snowe. Negotiations continued even after July 7 — when Franken was sworn into office, and by which time Specter had switched parties — due to disagreements over the substance of the bill, which was still being drafted in committee, and because moderate Democrats hoped to win bipartisan support. However, on August 25, before the bill could come up for a vote, Ted Kennedy—a long-time advocate for healthcare reform—died, depriving Democrats of their 60th vote. Before the seat was filled, attention was drawn to Senator Snowe because of her vote in favor of the draft bill in the Finance Committee on October 15, however she explicitly stated that this did not mean she would support the final bill.[75] Paul Kirk was appointed as Senator Kennedy's temporary replacement on September 24.
Following the Finance Committee vote, negotiations turned to the demands of moderate Democrats to finalize their support, whose votes would be necessary to break the anticipated Republican filibuster. Majority leader Harry Reid focused on satisfying the centrist members of the Democratic caucus until the holdouts narrowed down to Joe Lieberman of Connecticut, an independent who caucused with Democrats, and Ben Nelson, a conservative Democrat, representing Nebraska. Lieberman, despite intense negotiations in search of a compromise by Reid, refused to support a public option; a concession granted only after Lieberman agreed to commit to voting for the bill if the provision were not included,[75][92] although it had majority support in Congress.[93] There was debate among supporters of the bill about the importance of the public option,[94] although the vast majority of supporters concluded it was a minor part of the reform overall,[92] and that congressional Democrats' fight for it won various concessions, including conditional waivers allowing states to set up state-based public options such as Vermont's Green Mountain Care.[93][95]
With every other Democrat now in favor and every other Republican now overtly opposed, the White House and Reid moved on to addressing Senator Nelson's concerns in order to win filibuster-proof support for the bill;[96] they had by this point concluded "it was a waste of time dealing with [Snowe]"[97] because, after her vote for the draft bill in the Finance Committee, Snowe had come under intense pressure from the Republican Senate leadership who opposed the ACA.[98] After a final 13-hour negotiation, Nelson's support for the bill was won after two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges", which would require consumers to pay for the procedure out-of-pocket if the state so decided; and an amendment to offer a higher rate of Medicaid reimbursement for Nebraska.[70][99] The latter half of the compromise was derisively called the "Cornhusker Kickback"[100] and was later repealed by the subsequent reconciliation amendment bill.
On December 23, the Senate voted 60–39 to end debate on the bill: a cloture vote to end the filibuster by opponents. The bill then passed by a vote of 60–39 on December 24, 2009, with all Democrats and two independents voting for, and all Republicans voting against (except for Jim Bunning, who did not vote).[101] The bill was endorsed by the AMA and AARP.[102]
Several weeks after the vote, on January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the late Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain Republican filibusters.[70][103][104] The special election had become significant to the reform debate because of its effects on the legislative process. The first was a psychological one: the symbolic importance of losing the traditionally Democratic Massachusetts seat formerly held by Senator Ted Kennedy, a staunch supporter of reform, made many congressional Democrats concerned about the political cost of passing a bill.[105][106] The second effect was more practical: the loss of the Democratic supermajority complicated the legislative strategy of reform proponents.[106]
House
The election of Scott Brown meant Democrats could no longer break a filibuster in the Senate. In response, White House Chief of Staff Rahm Emanuel argued that Democrats should scale back for a less ambitious bill; House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care."[107][108] Obama also remained insistent on comprehensive reform, and the news that Anthem Blue Cross in California intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous Democrats after Scott Brown's win.[107][108] On February 22, President Obama laid out a "Senate-leaning" proposal to consolidate the bills.[109] He held a meeting with leaders of both parties on February 25. With Democrats having lost a filibuster-proof supermajority in the Senate but having already passed the Senate bill with 60 votes on December 24, the most viable option for the proponents of comprehensive reform was for the House to abandon its own health reform bill, the Affordable Health Care for America Act, and pass the Senate's bill, the Patient Protection and Affordable Care Act, instead.
Various health policy experts encouraged the House to pass the Senate version of the bill.[110] However, House Democrats were not happy with the content of the Senate bill and had expected to be able to negotiate changes in a House-Senate conference before passing a final bill.[106] With that option off the table, given that any bill which emerged from conference that differed from the Senate bill would have to be passed in the Senate over another Republican filibuster, most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill.[106] They drafted the Health Care and Education Reconciliation Act, which could be passed via the reconciliation process.[107][111][112]
Unlike rules under regular order, as per the Congressional Budget Act of 1974, reconciliation cannot be subject to a filibuster. However, the process is limited to budget changes, which is why the procedure was never able to be used to pass a comprehensive reform bill like the ACA in the first place; such a bill would have inherently non-budgetary regulations.[113][114] Whereas the already passed Senate bill could not have been put through reconciliation, most of House Democrats' demands were budgetary: "these changes—higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal—mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well - suited for reconciliation."[111]
The remaining obstacle was a pivotal group of pro-life Democrats led by Bart Stupak who were initially reluctant to support the bill. The group found the possibility of federal funding for abortion substantive enough to warrant opposition. The Senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill as it would be outside the scope of the process with its budgetary limits. Instead, President Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment.[115] This concession won the support of Stupak and members of his group and assured passage of the bill.[112][116] The House passed the Senate bill with a 219–212 vote on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.[117] The following day, Republicans introduced legislation to repeal the bill.[118] Obama signed the ACA into law on March 23, 2010.[119] The amendment bill, The Health Care and Education Reconciliation Act, was also passed by the House on March 21, by the Senate via reconciliation on March 25, and was signed by President Obama on March 30.
The election of Scott Brown meant Democrats could no longer break a filibuster in the Senate. In response, White House Chief of Staff Rahm Emanuel argued that Democrats should scale back for a less ambitious bill; House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care."[107][108] Obama also remained insistent on comprehensive reform, and the news that Anthem Blue Cross in California intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous Democrats after Scott Brown's win.[107][108] On February 22, President Obama laid out a "Senate-leaning" proposal to consolidate the bills.[109] He held a meeting with leaders of both parties on February 25. With Democrats having lost a filibuster-proof supermajority in the Senate but having already passed the Senate bill with 60 votes on December 24, the most viable option for the proponents of comprehensive reform was for the House to abandon its own health reform bill, the Affordable Health Care for America Act, and pass the Senate's bill, the Patient Protection and Affordable Care Act, instead.
Various health policy experts encouraged the House to pass the Senate version of the bill.[110] However, House Democrats were not happy with the content of the Senate bill and had expected to be able to negotiate changes in a House-Senate conference before passing a final bill.[106] With that option off the table, given that any bill which emerged from conference that differed from the Senate bill would have to be passed in the Senate over another Republican filibuster, most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill.[106] They drafted the Health Care and Education Reconciliation Act, which could be passed via the reconciliation process.[107][111][112]
Unlike rules under regular order, as per the Congressional Budget Act of 1974, reconciliation cannot be subject to a filibuster. However, the process is limited to budget changes, which is why the procedure was never able to be used to pass a comprehensive reform bill like the ACA in the first place; such a bill would have inherently non-budgetary regulations.[113][114] Whereas the already passed Senate bill could not have been put through reconciliation, most of House Democrats' demands were budgetary: "these changes—higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal—mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well - suited for reconciliation."[111]
The remaining obstacle was a pivotal group of pro-life Democrats led by Bart Stupak who were initially reluctant to support the bill. The group found the possibility of federal funding for abortion substantive enough to warrant opposition. The Senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill as it would be outside the scope of the process with its budgetary limits. Instead, President Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment.[115] This concession won the support of Stupak and members of his group and assured passage of the bill.[112][116] The House passed the Senate bill with a 219–212 vote on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.[117] The following day, Republicans introduced legislation to repeal the bill.[118] Obama signed the ACA into law on March 23, 2010.[119] The amendment bill, The Health Care and Education Reconciliation Act, was also passed by the House on March 21, by the Senate via reconciliation on March 25, and was signed by President Obama on March 30.
88. Maze, Rick (October 8, 2009). "House OKs tax breaks for military homeowners". Air Force Times. Retrieved March 24,
2010.
89. U.S. Const. art. I, § 7, cl. 1.
90. S.Amdt. 2786
91. Cohn, Jonathan (September 7, 2009). "Why Reform Survived August". The New Republic.
92. Hacker, Jacob S. (December 20, 2009). "Why I Still Believe in This Bill". The New Republic.
93. Cohn, Jonathan (March 12, 2010). "The Public Option, Still Dead". The New Republic.
94. "Is the House Healthcare Bill Better Than Nothing?". The Huffington Post. November 9, 2009. Retrieved January 12, 2012. 95. Cohn, Jonathan (December 15, 2009). "What Public Option Supporters Won". The New Republic.
96. Cohn, Jonathan (December 17, 2009). "Ben Nelson, Still a Big Problem (Updated)". The New Republic.
97. Raju, Manu (January 20, 2010). "Olympia Snowe puzzled by Harry Reid comments". Politico.
98. Chait, Jonathan (December 19, 2009). "The Republican Health Care Blunder". The New Republic.
Chait, Jonathan (January 19, 2010). "Revisiting Snowe's Lay Down". The New Republic.
Chait, Jonathan (March 16, 2010). "(Non)sense of Snowe". The New Republic.
99. Cohn, Jonathan (December 19, 2009). "BREAKING: Nelson Says Yes; That Makes 60". The New Republic.
100. "'Cornhusker' Out, More Deals In: Health Care Bill Gives Special Treatment". Fox News. March 19, 2010. Retrieved April
26, 2010.
101. "Roll Call vote No. 396 – On Passage of the Bill (H.R. 3590 as Amended)". U.S. Senate. Retrieved January 9, 2012.
102. "AARP, AMA Announce Support For Health Care Bill: Largest Doctors And Retiree Groups Backing Legislation". The
Huffington Post, March 19, 2010.
103. Applewhite, J. Scott. "Senator-elect Scott Brown welcomed as Republican hero after upset victory in Massachusetts".
McClatchy-Tribune News Service. Associated Press. Retrieved April 19, 2012.
104. "Public Statements – Project Vote Smart" (Press release). Votesmart.org. January 13, 2010. Retrieved April 9, 2012.
105. Silver, Nate (January 21, 2010). "Will the Base Abandon Hope?". FiveThirtyEight.
106. Cohn, Jonathan (January 17, 2010). "How to Pass the Bill--Whatever Happens Tuesday". The New Republic.
107. Stolberg, Sheryl; Zeleny, Jeff; Hulse, Carl (March 20, 2010). "Health Vote Caps a Journey Back From the Brink". The New
York Times. Retrieved March 23, 2010.
108. Brown, Carrie; Thrush, Glenn (March 20, 2010). "Pelosi steeled W.H. for health push". Politico. Retrieved March 23,
2010.
109. "White House Unveils Revamped Reform Plan, GOP And Industry React". Kaiserhealthnews.org. February 22, 2010.
Retrieved June 29, 2012.
110. Pollack, Harold. "47 (Now 51) Health Policy Experts (Including Me) Say 'Sign the Senate bill.'". The New Republic. Retrieved January 12, 2012.
111. Chait, Jonathan (February 20, 2010). "A Brief Reconciliation Primer". The New Republic.
112. Silver, Nate (December 26, 2009). "For Pelosi, Many Paths to 218". FiveThirtyEight.
113. Silver, Nate (January 21, 2010). "1. Reconciliation! 2. ??? 3. Profit!". FiveThirtyEight.
114. Cohn, Jonathan (September 21, 2009). "Reconciliation: Why Most Dems Don't Want to Go There". The New Republic.
115. Executive Order 13535 of March 24, 2010 — Ensuring Enforcement and Implementation of Abortion Restrictions in the
Patient Protection and Affordable Care Act, Vol. 75, No. 59 75 F.R. 15599, March 29, 2010.
116. Chait, Jonathan (March 21, 2010). "Stupak Makes A Deal, Reform To Pass". The New Republic.
117. "Roll Call vote No. 165: On Motion to Concur in Senate Amendments (Patient Protection and Affordable Care Act)". Office
of the Clerk: House of Representatives. March 21, 2010. Retrieved April 9, 2012.
118. Aro, Margaret; Mooney, Mark (March 22, 2010). "Pelosi Defends Health Care Fight Tactics". ABC News. Retrieved March
23, 2010.
119. Stolberg, Sheryl; Pear, Robert (March 23, 2010). "Obama Signs Health Care Overhaul Bill, With a Flourish". The New York
Times. Retrieved March 24, 2010.
2010.
89. U.S. Const. art. I, § 7, cl. 1.
90. S.Amdt. 2786
91. Cohn, Jonathan (September 7, 2009). "Why Reform Survived August". The New Republic.
92. Hacker, Jacob S. (December 20, 2009). "Why I Still Believe in This Bill". The New Republic.
93. Cohn, Jonathan (March 12, 2010). "The Public Option, Still Dead". The New Republic.
94. "Is the House Healthcare Bill Better Than Nothing?". The Huffington Post. November 9, 2009. Retrieved January 12, 2012. 95. Cohn, Jonathan (December 15, 2009). "What Public Option Supporters Won". The New Republic.
96. Cohn, Jonathan (December 17, 2009). "Ben Nelson, Still a Big Problem (Updated)". The New Republic.
97. Raju, Manu (January 20, 2010). "Olympia Snowe puzzled by Harry Reid comments". Politico.
98. Chait, Jonathan (December 19, 2009). "The Republican Health Care Blunder". The New Republic.
Chait, Jonathan (January 19, 2010). "Revisiting Snowe's Lay Down". The New Republic.
Chait, Jonathan (March 16, 2010). "(Non)sense of Snowe". The New Republic.
99. Cohn, Jonathan (December 19, 2009). "BREAKING: Nelson Says Yes; That Makes 60". The New Republic.
100. "'Cornhusker' Out, More Deals In: Health Care Bill Gives Special Treatment". Fox News. March 19, 2010. Retrieved April
26, 2010.
101. "Roll Call vote No. 396 – On Passage of the Bill (H.R. 3590 as Amended)". U.S. Senate. Retrieved January 9, 2012.
102. "AARP, AMA Announce Support For Health Care Bill: Largest Doctors And Retiree Groups Backing Legislation". The
Huffington Post, March 19, 2010.
103. Applewhite, J. Scott. "Senator-elect Scott Brown welcomed as Republican hero after upset victory in Massachusetts".
McClatchy-Tribune News Service. Associated Press. Retrieved April 19, 2012.
104. "Public Statements – Project Vote Smart" (Press release). Votesmart.org. January 13, 2010. Retrieved April 9, 2012.
105. Silver, Nate (January 21, 2010). "Will the Base Abandon Hope?". FiveThirtyEight.
106. Cohn, Jonathan (January 17, 2010). "How to Pass the Bill--Whatever Happens Tuesday". The New Republic.
107. Stolberg, Sheryl; Zeleny, Jeff; Hulse, Carl (March 20, 2010). "Health Vote Caps a Journey Back From the Brink". The New
York Times. Retrieved March 23, 2010.
108. Brown, Carrie; Thrush, Glenn (March 20, 2010). "Pelosi steeled W.H. for health push". Politico. Retrieved March 23,
2010.
109. "White House Unveils Revamped Reform Plan, GOP And Industry React". Kaiserhealthnews.org. February 22, 2010.
Retrieved June 29, 2012.
110. Pollack, Harold. "47 (Now 51) Health Policy Experts (Including Me) Say 'Sign the Senate bill.'". The New Republic. Retrieved January 12, 2012.
111. Chait, Jonathan (February 20, 2010). "A Brief Reconciliation Primer". The New Republic.
112. Silver, Nate (December 26, 2009). "For Pelosi, Many Paths to 218". FiveThirtyEight.
113. Silver, Nate (January 21, 2010). "1. Reconciliation! 2. ??? 3. Profit!". FiveThirtyEight.
114. Cohn, Jonathan (September 21, 2009). "Reconciliation: Why Most Dems Don't Want to Go There". The New Republic.
115. Executive Order 13535 of March 24, 2010 — Ensuring Enforcement and Implementation of Abortion Restrictions in the
Patient Protection and Affordable Care Act, Vol. 75, No. 59 75 F.R. 15599, March 29, 2010.
116. Chait, Jonathan (March 21, 2010). "Stupak Makes A Deal, Reform To Pass". The New Republic.
117. "Roll Call vote No. 165: On Motion to Concur in Senate Amendments (Patient Protection and Affordable Care Act)". Office
of the Clerk: House of Representatives. March 21, 2010. Retrieved April 9, 2012.
118. Aro, Margaret; Mooney, Mark (March 22, 2010). "Pelosi Defends Health Care Fight Tactics". ABC News. Retrieved March
23, 2010.
119. Stolberg, Sheryl; Pear, Robert (March 23, 2010). "Obama Signs Health Care Overhaul Bill, With a Flourish". The New York
Times. Retrieved March 24, 2010.
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Fair Use Notice Act Disclaimer: This website may contain copyrighted material of which use may not be authorized by the copyright owners. Under section 107 through 118 of the Copyright Act 1976, allowance is made for "fair use" for purposes such as criticism, comment, news reporting, teaching, scholarship, education, and research. If you wish to use this material that goes beyond fair use, you must obtain permission from the copyright owner. Fair use notwithstanding, I will comply with any copyright owner who wants their material removed, modified, or wants me to link to their website, or wants us to add their photo.
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